Percutaneous screw fixation for the acetabular fracture with quadrilateral plate involved by three-dimensional fluoroscopy navigation: surgical technique

The Long-Term Clinical and Radiographic Outcomes of Cerclage Cable Fixation for Displaced Acetabular Fractures Using a Posterior Approach: A Retrospective Cohort Study

Background and Objectives: Cerclage cable fixation with 2 mm multiple-braided cables for displaced acetabular fractures has shown good midterm functional and radiographic outcomes. We retrospectively evaluated the clinical and radiographic outcomes of cerclage cable fixations over ten years. Materials and Methods: We extracted data for patients who underwent cerclage cable fixation for acetabular fractures at a single institution from 2007 to 2012. We adopted this procedure for acetabulum fractures with posterior column fractures. Postoperative reduction quality, complications, reoperations, and Japanese Orthopedic Association (JOA) hip objective functional scores were analyzed. Postoperative reduction quality was classified using plain radiography and computed tomography. Results: We evaluated nine patients with a mean follow-up period of 14.1 ± 2.6 years (range: 10.8-18.1 years). The mean age was 47.1 ± 15.5 years old (range: 28-74 years); the mean injury severity score was 13.6 ± 4.7 (range: 9-22). The most frequent type of fracture was a both-column fracture. Anatomical reduction quality was achieved in five cases. Four patients had hip osteoarthritis at the last follow-up; among them, one patient had worsening hip arthritis > 5 years after surgery, and one patient developed osteoarthritis > 10 years after surgery. Their postoperative reduction quality was worse than their anatomical reduction quality, and both engaged in physical labor. None of the patients underwent revision total hip arthroplasty. The mean JOA hip score was 90.9 ± 7.9 (range: 74-100); seven patients scored >90 at the last follow-up. Conclusions: Cerclage cable fixation showed satisfactory postoperative reductions and favorable long-term clinical outcomes. Long-term follow-up might be necessary for patients whose postoperative reduction is not anatomical to detect late occurrence of hip osteoarthritis, even if osteoarthritis is not evident during short-term follow-up periods.

Quadrilateral plate fractures of the acetabulum: Classification, approach, implant therapy and related research progress

The quadrilateral plate (QP) is an essential structure of the inner wall of the acetabulum, an important weight-bearing joint of the human body, which is often involved in acetabular fractures. The operative exposure, reduction and fixation of QP fractures have always been the difficulties in orthopedics due to the special morphological structure and anatomical features of the QP. Fortunately, there have been many effective methods and instruments developed for QP exposure, reduction and fixation by virtue of the combined efforts of numerous orthopedists. At the same time, each method presents with its own advantages and disadvantages, resulting in different prognoses. It is necessary to have a thorough understanding of the anatomy, radiology and fixation techniques of the QP in terms of patient prognosis optimization. In this paper, the anatomical features, definition and classification of QP, operative approach selection, implant internal fixation methods and efficacy were reviewed.

Traditional versus mirror three-dimensional printing technology for isolated acetabular fractures: a retrospective study with a median follow-up of 25 months

Objective

To assess the outcomes of traditional three-dimensional (3D) printing technology (TPT) versus mirror 3D printing technology (MTT) in treating isolated acetabular fractures (IAFs).

Methods

Consecutive patients with an IAF treated by either TPT or MTT at our tertiary medical centre from 2012 to 2018 were retrospectively reviewed. Follow-up was performed 1, 3, 6, and 12 months postoperatively and annually thereafter. The primary outcome was the Harris hip score (HHS), and the secondary outcomes were major intraoperative variables and key orthopaedic complications.

Results

One hundred fourteen eligible patients (114 hips) with an IAF (TPT, n = 56; MTT, n = 58) were evaluated. The median follow-up was 25 months (range, 21–28 months). At the last follow-up, the mean HHS was 82.46 ±14.70 for TPT and 86.30 ± 13.26 for MTT with a statistically significant difference. Significant differences were also detected in the major intraoperative variables (operation time, intraoperative blood loss, number of fluoroscopic screenings, and anatomical reduction number) and the major orthopaedic complications (loosening, implant failure, and heterotopic ossification).

Conclusion

Compared with TPT, MTT tends to produce accurate IAF reduction and may result in better intraoperative variables and a lower rate of major orthopaedic complications.

Traditional three-dimensional printing technology versus three-dimensional printing mirror model technology in the treatment of isolated acetabular fractures: a retrospective analysis

OBJECTIVE

This study was performed to compare the clinical outcomes of traditional three-dimensional (3D) printing technology and 3D printing mirror model technology in the treatment of isolated acetabular fractures.

METHODS

Prospectively maintained databases were reviewed to retrospectively compare patients with an isolated acetabular fracture who were treated with traditional 3D printing technology (Group T) or 3D printing mirror model technology (Group M) from 2011 to 2017. In total, 146 advanced-age patients (146 hips) with an isolated acetabular fracture (Group T, n = 72; Group M, n = 74) were assessed for a mean follow-up period of 29 months (range, 24-34 months). The primary endpoint was the postoperative Harris hip score (HHS). The secondary endpoints were the operation time, intraoperative blood loss, fluoroscopy screening time, fracture reduction quality, and incidence of postoperative complications at the final follow-up.

RESULTS

The HHS, operation time, intraoperative blood loss, fluoroscopy screening time, and incidence of postoperative complications were significantly different between the groups, with Group M showing superior clinical outcomes.

CONCLUSION

In patients with an isolated acetabular fracture, 3D printing mirror model technology might lead to more accurate and efficient treatment than traditional 3D printing technology.

Open reduction and internal fixation of quadrilateral plate fractures in the elderly: association between initial fracture pattern and outcomes

Background

Acetabular fractures with medial displacement of the quadrilateral plate (QLP) are common in the elderly. The presence of QLP fractures greatly increase the surgical difficulty of acetabular fractures. This study aims to evaluate the clinical radiological outcomes of open reduction and internal fixation (ORIF) in QLP fractures in elderly patients and to investigate factors potentially affecting the result.

Methods

We conducted a retrospective study. A series of 37 consecutive patients with acetabular fracture involving the QLP aged 60 years and older who received ORIF between January 2010 and May 2019 were included. QLP fractures were classified according to Walid’s classification system. Radiological outcomes were evaluated using Matta criteria and functional outcomes were assessed using the modified Merle d’Aubigné score. The relationships between Walid’s classification and radiological or functional outcomes were analyzed.

Results

According to Walid’s classification, 18, 13, 6 were classified as QLP1, QLP2 and QLP3, respectively. The average follow-up was 35.5 ± 10.7 months. We obtained anatomic reduction in 48.6 % (18/37) of cases, imperfect reduction in 40.5 % (15/37) of cases, and poor reduction in 10.8 % (4/37) of cases. Excellent-good functional scores were found in 83.7 % (modified Merle d’Aubigné). There were no cases of screw entering the hip, pull-out and loosening or implant failure during the follow-up. Walid’s classification was positively correlated with radiological outcomes of reduction (r = 0.661; P < 0.001), and functional outcomes (r = 0.478; P = 0.003). Unsatisfactory reduction was demonstrated a correlation with the development of post-traumatic arthritis (r =-0.410; P = 0.012).

Conclusions

ORIF may be suggested for quadrilateral plate fractures in the elderly. Walid’s classification system is associated with the reduction quality and functional recovery.

Computer-Assisted Orthopedic and Trauma Surgery

BACKGROUND

There are many ways in which computer-assisted orthopedic and trauma surgery (CAOS) procedures can help surgeons to plan and execute an intervention.

METHODS

This study is based on data derived from a selective search of the literature in the PubMed database, supported by a Google Scholar search.

RESULTS

For most applications the evidence is weak. In no sector did the use of computer-assisted surgery yield any relevant clinical or functional improvement. In trauma surgery, 3D-navigated sacroiliac screw fixation has become clinically established for the treatment of pelvic fractures. One randomized controlled trial showed a reduction in the rate of screw misplacement: 0% with 3D navigation versus 20.4% with the conventional procedure und 16.6% with 2D navigation. Moreover, navigation-assisted pedicle screw stabilization lowers the misplacement rate. In joint replacements, the long-term results showed no difference in respect of clinical/functional scores, the time for which the implant remained in place, or aseptic loosening.

CONCLUSION

Computer-assisted procedures can improve the precision of certain surgical interventions. Particularly in joint replacement and spinal surgery, the research is moving away from navigation in the direction of robotic procedures. Future studies should place greater emphasis on clinical and functional results.

Utility of an image fusion system for 3D preoperative planning and fluoroscopy in the osteosynthesis of distal radius fractures

Background

Recently, computerized virtual surgery planning has been increasingly applied in various orthopedic procedures. In this study, we developed an image fusion system for 3D preoperative planning and fluoroscopy for the osteosynthesis. To assess the utility of image fusion system, we evaluated the reproducibility of preoperative planning in the osteosynthesis of distal radius fractures with using the image fusion system, and compared with the reproducibility of the patients without using the image fusion system.

Methods

Forty-two wrists of 42 distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. The patients were divided into two groups. Image fusion group utilized three-dimensional (3D) preoperative planning and image fusion system. Control group utilized only 3D preoperative planning. In both groups, 3D preoperative planning was performed in order to determine reduction, placement, and choice of implants. In the image fusion group, the outline of planned image was displayed on a monitor overlapping with fluoroscopy images during surgery. Reductions were evaluated by volar tilt and radial inclination of 3D images. Plate positions were evaluated with distance to joint surface, plate center axis position, and inclination relative to the radius axis. Screw choices were recorded for the plan and actual choices for each screw hole. Differences in the parameters between pre- and postoperative images were evaluated. Differences in reduction shape, plate positions, and screw choices were compared between groups.

Results

The differences in the distance from plate to joint surface were significantly smaller in the image fusion group compared to the control group (P < 0.01). The differences in the distal screw choices were significantly smaller in the image fusion group compared to the control group (P < 0.01).

Conclusions

The image fusion system was useful to reproduce the planned plate position and distal screw choices in the osteosynthesis of distal radius fractures.

Trial registration

ClinicalTrials.gov, NCT03764501

Establishment of fluoroscopy views and standardized procedure of percutaneous magic screw insertion for acetabulum fractures

Background

To place the magic screw more simply, we established a set of reproducible fluoroscopic views and a standardized procedure of magic screw insertion.

Materials and methods

This study on the magic screw tunnel uses a three-dimensional reconstruction model and a skeleton projection. The 3D model of the pelvis was made to be transparent and it was rotated to the place where the ischial spine was just sheltered by the posterior wall of the acetabulum. The angles of this view projection were recorded in the transverse plane and coronal plane. Six cadaveric pelvises (three males, three female) were used to validate the proper projection angle of the C-arm fluoroscopy. The skeleton specimens were all positioned latericumbent on a radiolucent table.

Result

In all pelvis 3D models, all magic cylinders with a 7.3 mm diameter were successfully inserted along the bone structure tunnel in 30 3D pelvic models. The average angle of the transverse view rotated by the C-arm fluoroscopy was 162° in males and 157° in females, the angle of the coronal plane was 22° in males and 24° in females. The average distance between the front wheel of the C-arm machine and the middle axial line of the radiolucent bed was 43 cm in males and 43 cm in females. In skeleton pelvis research, all the screws were safely inserted using this method.

Conclusion

The magic screw technique could be a good choice for the treatment of acetabular fractures, especially quadrilateral plate fractures. If the proper fluoroscopy view technique is used properly, the magic screw can be inserted rapidly and safely.

Is there a need for standardized postoperative radiographs after operative treatment of wrist or ankle fractures?

PURPOSE

The purpose of this study was to evaluate the frequency of changes in treatment plan due to standardized postoperative radiographs. A secondary aim was to compare our results with a national benchmark.

METHODS

This is a single-center retrospective case series of 167 consecutive patients, operated with open reduction and internal fixation (ORIF) for distal radius or ankle fractures in 2014. Changes in the treatment protocol were defined as additional CT-imaging, reoperation or other changes as stated in the postoperative instructions. In addition, a national survey was conducted assessing differences between surgeons in different hospitals concerning revision rates.

RESULTS

In 7.2% (12/167) of the patients, a change in the treatment plan was recorded after the standardized postoperative radiographs. 10 patients (6%) were reoperated (three without additional imaging, seven after additional imaging with CT). The results from our survey showed a good assessment concerning the quality of intraoperative imaging (7.85 on a scale from 0 to 10). Concerning the revision rate, there was a trend to lower revision rate of 8.1% in the six observers.

CONCLUSIONS

Standard postoperative radiographs could improve quality of care. Intraoperative standardized radiographic documentation is needed and the perception and acceptance of quality may vary between hospitals.

Percutaneous fixation of acetabular fractures

The objective of surgery for acetabular fractures is to achieve precise reduction to restore joint congruence, fix internal bone fragments, avoid displacement of the fracture and allow rapid rehabilitation.Open reduction and internal fixation is the benchmark method for displaced acetabular fractures, but open reductions can increase morbidity, causing neurovascular injury, blood loss, heterotopic bone formation, infection and poor wound healing.An anatomical reduction with a gap of 2 mm or less is a predictor of good joint function and reduced risk of post-traumatic osteoarthritis.The percutaneous approach is associated with fewer complications than open techniques, but acetabular geometry makes percutaneous screw insertion a challenging procedure.The percutaneous technique is recommended for non-displaced or slightly displaced fractures, and in obese, osteoporotic and elderly patients who cannot receive total joint arthroplasty.We recommend the use of intramedullary cannulated screws.Fracture reductions are achieved by manual traction of the affected bones. If some fracture displacement remains, accessory windows can be used to introduce a ball spike pusher, a hook or a Steinmann pin which can be used as a joystick to rotate the fracture.In this paper, we describe the accessory windows for the anterior column, the quadrilateral plate and the posterior column. We detail the position, direction and kind of screws used to stabilize the anterior and posterior columns. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170054.

Accurate fixation of plates and screws for the treatment of acetabular fractures using 3D-printed guiding templates: An experimental study

OBJECTIVE

To investigate the feasibility of the use of 3D-printed guiding templates for accurate placement of plates and screws for internal fixation of acetabular fractures.

METHODS

3D models of the pelvises of 14 adult cadavers were reconstructed using computed tomography (CT). Twenty-eight acetabular fractures were simulated and placement positions for plates and screw trajectories were designed. Bending module was obtained by 3D cutting; guiding template was manufactured using 3D printing, and the plate was pre-bent according to the bending module. Plates and screws were placed in cadaveric pelvises using the guiding template, and 3D model was reconstructed using CT. The designed and real trajectories were matched using 3D registration including the coordinates (entry and exit points) of designed trajectory. The number of qualified points with different accuracy levels was compared using Chi-squared test.

RESULTS

Sixty-four plates and 339 screws were placed with no cortical breach. The absolute difference of the X, Y, and Z coordinates between the designed and real entry points were 0.52±0.45, 0.43±0.36, and 0.53±0.44mm, respectively. The corresponding values for the exit points were 0.83±0.67, 1.22±0.87, and 1.26±0.83mm, respectively. With an accuracy degree ≥1.9mm for the entry points and ≥3.8mm for the exit points, there was no significant difference between the designed and the real trajectories.

CONCLUSION

The 3D-printed guiding template helped achieve accurate placement of plates and screws in the pelvis of adult cadavers.

A rare case of bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture in an elderly male due to seizure activity

Musculoskeletal injuries such as dislocation of the shoulder and hip joints and fractures of the femoral neck are known complications of seizures. Bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture is a rare entity and is prone to delayed diagnosis, even more so in patients who experience post-seizure disorientation. The authors report the case of a 74-year-old male patient with bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture due to seizure activity. Bilateral open reconstruction and fixation of the quadrilateral plate with a 3.5-mm pre-bent reconstruction plate reinforced with 3.5-mm pelvic brim reconstruction plate was performed. In conclusion, this case is an example of rare bilateral quadrilateral plate fracture caused due to seizure activity, a fracture for which a high level of suspicion should be kept in mind while evaluating the patient post-seizure episode.

Comparison of Isocentric C-Arm 3-Dimensional Navigation and Conventional Fluoroscopy for Percutaneous Retrograde Screwing for Anterior Column Fracture of Acetabulum: An Observational Study

Percutaneous screw insertion for minimally displaced or reducible acetabular fracture using x-ray fluoroscopy and computer-assisted navigation system has been advocated by some authors. The purpose of this study was to compare intraoperative conditions and clinical results between isocentric C-arm 3-dimensional (Iso-C 3D) fluoroscopy and conventional fluoroscopy for percutaneous retrograde screwing of acetabular anterior column fracture.A prospective cohort study was conducted. A total of 22 patients were assigned to 2 different groups: 10 patients in the Iso-C 3D navigation group and 12 patients in the conventional group. The operative time, fluoroscopic time, time of screw insertion, blood loss, and accuracy were analyzed between the 2 groups.There were significant differences in operative time, screw insertion time, fluoroscopy time, and mean blood loss between the 2 groups. Totally 2 of 12 (16.7%) screws were misplaced in the conventional fluoroscopy group, and all 10 screws were in safe zones in the navigation group. Percutaneous screw fixation using the Iso-C 3D computer-assisted navigation system significantly reduced the intraoperative fluoroscopy time and blood loss in percutaneous screwing for acetabular anterior column fracture.The Iso-C 3D computer-assisted navigation system provided a reliable and effective method for percutaneous screw insertion in acetabular anterior column fractures compared to conventional fluoroscopy.

A novel electromagnetic navigation tool for acetabular surgery

BACKGROUND

Acetabular fracture surgery is demanding and screw placement along narrow bony corridors remains challenging. It necessitates x-ray radiation for fluoroscopically assisted screw insertion. The purpose of this cadaver study was to evaluate the feasibility, accuracy and operation time of a novel electromagnetic navigation system for screw insertion along predefined acetabular corridors.

METHODS

A controlled laboratory study with a total of 24 electromagnetically navigated screw insertions was performed on 8 cadaveric acetabula. 3 peri-acetabular bony corridors (QSS, Quadrilateral Surface Screw; IAS, Infra-Acetabular Screw; PCS, Posterior Column Screw) were defined and screws were placed in a defined order without fluoroscopy. Operation time was documented. Postoperative CT scans were performed to analyse accuracy of screw placement.

RESULTS

Mean cadaver age was 70.4 ± 11.7. Successful screw placement was accomplished in 22 out of 24 (91.7%) cases. The overall mean time for all 3 acetabular screws was 576.6 ± 75.9s. All 3 complications occurred during the placement of the IAS due to an impassable narrow bony corridor. QSS mean length was 50 ± 5mm, IAS mean length was 85 ± 10mm and PCS mean length was 120 ± 5mm.

CONCLUSION

In this cadaver study the novel electromagnetic navigation system was feasible to allow accurate screw placement without fluoroscopy in defined narrow peri-acetabular bony corridors.

A novel fixation system for acetabular quadrilateral plate fracture: a comparative biomechanical study

This study aims to assess the biomechanical properties of a novel fixation system (named AFRIF) and to compare it with other five different fixation techniques for quadrilateral plate fractures. This in vitro biomechanical experiment has shown that the multidirectional titanium fixation (MTF) and pelvic brim long screws fixation (PBSF) provided the strongest fixation for quadrilateral plate fracture; the better biomechanical performance of the AFRIF compared with the T-shaped plate fixation (TPF), L-shaped plate fixation (LPF), and H-shaped plate fixation (HPF); AFRIF gives reasonable stability of treatment for quadrilateral plate fracture and may offer a better solution for comminuted quadrilateral plate fractures or free floating medial wall fracture and be reliable in preventing protrusion of femoral head.

A reduction clamp for an aiming component in associated acetabular fractures

BACKGROUND

The treatment of acetabular fractures is complex and requires specialized equipment. However, all currently available instruments have some disadvantages. A new reduction clamp that can firmly enable reduction and not hinder subsequent fixation procedures for some special fracture types is needed.

MATERIALS AND METHODS

In this study, we introduce a new acetabular clamp and its preliminary clinical application in three T-shaped acetabular fractures.

RESULTS

This new clamp can successfully pull the posterior column back to the anterior column and firmly maintain the reduction. This clamp's aiming plate can facilitate the insertion of long lag screws. The clamp is also easy to assemble and use.

CONCLUSION

This reduction clamp is a useful instrument that can facilitate open reduction and internal fixation of acetabular fractures.

Quadrilateral plate fractures of the acetabulum: an update

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

Cup-cage construct for acute fractures of the acetabulum, re-defining indications

Acetabular fractures in the elderly are challenging injuries. The use of a trabecular metal acetabular cage was investigated as the treatment option in a series of elderly patients with acetabular fractures. At a 2-year follow up, 6 elderly patients were found to have mimimum pain, increased function, and increased scores using the Merle d'Aubigné and Postel system modified by Charnley. Radiographically, the areas of morsellised autograft that surrounded the cups were seen to have incorporated uniformly well, and the acetabular fractures were healed within six months after surgery. No mechanical failure, screw breakage, loosening, or migration was noticed. This novel indication of the cup-cage construction that uses revision techniques, for selected patients and fractures, to achieve an acute stable reconstruction, should be considered as an alternative reconstruction option in elderly patients presenting with acetabular fractures.